Lipid-lowering drugs

Question 1

when should lipid lowering therapy be offered?

Answer 1

For primary prevention of CVD in people:

• aged <84 if QRISK assessment >=10%
• T2DM + other CVD risk factors
• T1DM
• CKD
• familial hypercholesterolaemia
• consider offering if age >=85

For secondary prevention of CVD in adults with established CVD, e.g. past or current Hx of MI, angina, stroke, TIA or PAD.

Question 2

which investigations should be performed before initiation treatment?

Answer 2

1. Full lipid profile: total cholesterol, HDL and non-HDL cholesterol and triglycerides
2. LFTs - contraindicated in active liver disease
3. renal function tests - dose adjustments required in CKD
4. HbA1c - to Dx possible DM
5. TSH - hypothyroidism is recognised cause of dyslipidaemia and untreated hypothyroidism increases risk of statin induced myopathy
6. if pt has generalised unexplained muscle pain, measure CK levels - if 5x or more upper limit of normal, re-measure after 7 days; if still high, seek specialist advice.

Question 3

which lipid modification therapies would you offer for primary and secondary prevention of CVD?

Answer 3

1. Primary prevention:
   - 1st line: 20 mg ATORVASTATIN - aim for >40% reduction in baseline non-HDL cholesterol
   - 2nd line: reinforce adherence to lifestyle changes, consider increasing dose and if target still not achieved, consider co-prescription of EZETIMIBE in pts with primary hypercholesterolaemia
2. Secondary prevention: 80 mg ATORVASTATIN

Question 4

what is the MOA of statins?

Answer 4

Inhibit HMG CoA reductase… decreased hepatic cholesterol synthesis.

Question 5

suggest characteristic ADRs of statins

Answer 5

1. myopathy: inc. myalgia, myositis, rhabdomyolysis and asymptomatic raised CK
2. liver impairment: check LFTs at baseline, 3 mths and 12 mths (discontinue if ALT/AST rise to and persist 1 3x upper limit of reference range

Question 6

what time of day should statins be taken?

Answer 6

At night as time is when majority of cholesterol synthesis takes place.

Question 7

what is the MOA of ezetimibe?

Answer 7

inhibits cholesterol Rs on enterocytes, inhibition absorption from small intestine